Stress Urinary Incontinence

Dr Zohreh Bartani

Classification

• Patients with SUI can be classified as ‘uncomplicated’ and ‘complicated’ . The Panel reached consensus on the definition to be used throughout this Guideline document:

• Women with uncomplicated SUI: no history of prior surgery for SUI, no prior extensive pelvic surgery, no prior pelvic radiation treatment, no neurogenic LUT dysfunction, no bothersome genitourinary prolapse, absence of voiding symptoms, and no medical conditions that affect the LUT.

• In cases where additional significant storage symptoms, especially OAB, are present, consider a possible diagnosis of MUI

• Women with complicated SUI: previous surgery for incontinence or previous extensive pelvic surgery, a history of pelvic irradiation, the presence of anterior or apical POP, the presence of voiding symptoms or the presence of neurogenic LUT dysfunction, and with significant OAB/UUI

Diagnotic evalution

• History and physical examination

• There is universal agreement that taking a history should be the first step in the assessment of anyone with UI. When the history categorises UI as probable SUI the presence of complicated or uncomplicated SUI can also be determined.

• There is little evidence from clinical trials that carrying out a clinical examination improves clinical outcomes, but there is widespread consensus that it remains an essential part of the assessment of women with SUI. It should include abdominal examination, vaginal examination and a careful assessment of any associated pelvic POP, examination of the perineum and evaluation of PFM strength, as well as a neuro-urological examination.

• An attempt to reproduce the SUI should be made.

• A standing cough test has a higher sensitivity for the diagnosis of SUI compared to a supine cough test .

• Despite this, the ICS has proposed a standardisation of the female cough stress test that includes a supine/lithotomy position with 200-400 mL of fluid in the bladder and 1–4 coughs .

• Patient questionnaires

• Post-void residual volume

• It is important to evaluate PVR in patients with SUI, in particular in patients who also have voiding symptoms or POP. The prevalence of a significant PVR in patients with SUI is uncertain, partly because of the lack of a standard definition of an abnormal PVR volume. Most studies investigating PVR have not included patients with SUI. In general, the data on PVR can only be applied with caution to adults with non-neurogenic SUI.

• In a cohort study of over 900 women with SUI, there was good correlation between PVR estimated by US and measured by catheterisation. The mean PVR was 39 mL measured by catheterisation and 63 mL estimated by US, with only 16% of women having a PVR > 100 mL

• Urodynamics

• Urodynamic testing is widely used as an adjunct to clinical diagnosis, based on the assumption that it may help to provide or confirm diagnosis. The role of urodynamics in SUI evaluation remains poorly defined and is still under debate.

• Invasive urodynamic tests are often performed prior to surgical treatment of SUI. Clinical diagnosis of incontinence and cystometricfindings often do not correlate .

• The diagnostic accuracy of urethral pressure profilometry and VLPPmeasurement in SUI is generally poor .

• Measurement of MUCP correlates, although weakly, with incontinence severity and there is conflicting evidence about its reproducibility

• Pad testing

• The clinical utility of pad tests for people with UI has been assessed in two systematic reviews .

• A one-hour pad test using a standardised exercise protocol and a diagnostic threshold of 1.4 g shows good specificity but low sensitivity for the diagnosis of SUI and MUI.

• A 24-hour pad test using a threshold of 4.4 g is more reproducible but is difficult to standardise with variation according to activity level

• Pad testing using a standardised bladder volume (50% of cystometriccapacity) has been suggested to allow for a more reliable assessment of UI in a small study including 25 women .

• There is no evidence that one type of pad test is superior to another.

• Once the diagnosis of pure SUI or mixed incontinence with a predominant “stress component” is made with confidence then treatment modalities should be fully discussed with the affected patient and all options, both surgical and non-surgical, should be outlined.

•Conservative management of SUI is beyond the scope of this review but options include behavioral therapy, timed voiding, fluid management, smoking and caffeine reduction, weight loss, and other lifestyle modifications.

• Perhaps the strongest body of evidence for conservative treatment supports the use of pelvic floor muscle training (PFMT) or biofeedback.

• Wilson et al reviewed the current evidence for PFMT at the International Consultation on Incontinence 200 and concluded that the overwhelming majority of the trials showed effectiveness of PFMT.

• In addition, the recommendation that PFMT should be offered, as first line therapy, to all women with stress, urge or mixed incontinence was made.

• Biofeedback techniques including the use of vaginal cones was also evaluated at this consultation with the conclusion that biofeedback was better than no treatment but not superior to PFMT.

• If conservative measures fail then surgical treatments are considered; these can be sub-divided based on four major types of procedure;

• Peri-urethral bulking agent injection

• Retropubic suspension (colposuspension, paravaginal repair)

• Sling and tape procedures (including sub-urethral tapes and urethral/bladder neck slings)

• Artificial urinary sphincter devices

• Peri-urethral bulking agent injection

• Retropubic suspension (colposuspension, paravaginal repair)

• Sling and tape procedures (including sub-urethral tapes and urethral/bladder neck slings)

• Artificial urinary sphincter devices

Bulking agents

• The advantages of this technique include the low associated morbidity. There is a range of injectable materials from autologous fat, through collagen to manufactured polymers (Teflon, Durasphere, Macroplastique). Autologous fat and PTFE are not widely used due to concerns about their safety profiles.

RETROPUBIC SUSPENSION PROCEDURES

• Retropubic suspension procedures are mainly intended for the treatment of SUI secondary to urethral hypermobility (types 1 and 2 in the Blaivas classification) and a wide variety of different techniques are available.

• All have the common underlying principle of elevating and fixing the bladder neck and proximal urethra in a retropubic position to enhance support.

• The most widely used technique is the Burch colposuspension and this procedure has been used as a gold standard with which to compare newer surgical treatments for SUI.

• Due to its higher rate of cure and more durable cure rates, Burch colposuspension should be regarded as the standard open retropubic suspension procedure according to a recent review.

Burch colposusoention

MMK

Vagino-obt & Burch

• The development of the TVT led to trials of a similar low tension sub-urethral tape but using a different route of access; the trans-obturator tape (TOT) again uses mid-urethral tape placement but instead of anchoring supra-pubically like a TVT, it anchors through the obturator foramen.

• Longer term and comparative data have recently emerged and a 2009 Cochrane review has examined the evidence for sub-urethral tapes in detail.

• This report describes the trans-obturator route as less favorable than the retropubic route in terms of objective cure but equivalent in terms of subjective cure. However, there was less voiding dysfunction, blood loss, bladder perforation, and shorter operating time with the trans-obturator route.

ARTIFICIAL URINARY SPHINCTER DEVICES

•Artificial urinary sphincter (AUS) insertion dates back to the 1970s. The increase in outlet resistance provided by an inflatable cuff around the proximal urethra keeps the patient dry when the cuff is activated and allows bladder emptying when it is not.

• The patient with SUI has a large number of surgical options to consider and this review can help with counseling for health care providers within this clinical area.

• The wealth of data has been accurately recorded and summarized by several well-conducted meta-analyses.

• Indeed in a recently published survey conducted by the International Urogynaecology Association, TVT was the preferred primary incontinence procedure for 68% of responders.

• Since the introduction of the TVT in 1996, the popularity of this procedure has grown exponentially.

•Although pubo-vaginal slings, bulking agents, retropubic suspensions, and AUS insertion are effective treatments for SUI as described above, their use is limited to individual cases and current practice appears to suggest an overwhelming preference for sub-urethral tapes.

•THANKS FOR ATTENTION